Medical preparation for travel is increasingly important. Not only are there more serious health risks present around the world, but there is more available for prevention and treatment. Opportunities for prevention should not be overlooked by any traveler, regardless of destination.

AFC Urgent Care offers immunizations for many types of diseases. To expedite your care, AFC Urgent Care has set up an on-line questionnaire for you to complete prior to your visit. Your AFC Urgent Care physician will then customize an immunization program for you based on the information you provide and can help you assemble the medications necessary that will help protect you against malaria, food and water borne diarrhea illness, and motion sickness.

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Please complete the form below to get started on your vaccinations.

Name

Sex

Date of Birth (MM/DD/YYYY)

Phone

Email

Your Destination

Dates of Tip

Purpose of your trip

Are you currently treated for any medical problems

Have you has a significant medical problem in the past

Could you be pregnant?

Are you staying mostly in cities/tourist destinations

Are you going to spend time in a rural area

Are you going to spend time above 5000 ft

Are you going to work in the foreign country

Are you allergic to eggs or chicken products

Have you has any hypersensitivity or reaction to vaccinations

Have you had Guillain-Barre Syndrome

Have you had all of your childhood vaccinations

Have you had tetanus/diphtheria vaccination in the last 10 years

Have you had measles vaccination (2 shots)

Have you had polio vaccination as an adult

Have you had hepatitis A vaccination (2 shots)

Have you had hepatitis B vaccination (3 shots)

Have you had meningitis vaccination in the past 3 years

Have you had typhoid vaccination in the past 2 yeats (if injected), or in the past 5 years (if oral)

Have you had yellow fever vaccination in the past 10 years

Have you had Japanese encephalitis vaccination in the past 2 years

List current or previous significant medical conditions

List current medications

Comments/Questions